Medical Coding CPT, ICD-10-CM Codes Patient number: 410327 Gender: Female? Body System: Musculoskeletal system

  Medical Coding CPT, ICD-10-CM Codes

Patient number: 410327

Gender: Female 

Body System: Musculoskeletal system

INDICATIONS: This is a 56 year old female with right hand ring finger trigger digit that has been  recalcitrant to conservative treatment options. Patient wishes to proceed with surgical release. Risks,  benefits, and alternatives to the procedure were discussed with the patient in detail preoperatively.  Risks include, but not limited to, infection, damage to blood vessels or nerves, stiffness of fingers,  thumb, and wrist, and need for further surgery. Patient verbalized understanding of these risk and  consented to proceed.   PREOPERATIVE DIAGNOSIS: Right hand ring finger trigger digit  POSTOPERATIVE DIAGNOSIS: Right hand ring finger trigger digit  OPERATION PERFORMED: Right hand ring finger trigger digit release  SURGEON  ASSISTANT SURGEON  ANESTHESIA: Local with monitored anesthesia care  COMPLICATIONS: None.  ESTIMATED BLOOD LOSS: Minimal  TOURNIQUET TIME: 10 minutes at 250 mmHg  FINDINGS:  —- Complete release of the A 1 pulley with full passive flexion and extension of the affected digit without  triggering.  INDICATIONS: This is a 56 year old female with right hand ring finger trigger digit that has been  recalcitrant to conservative treatment options. Patient wishes to proceed with surgical release. Risks,  benefits, and alternatives to the procedure were discussed with the patient in detail preoperatively.  Risks include, but not limited to, infection, damage to blood vessels or nerves, stiffness of fingers,  thumb, and wrist, and need for further surgery. Patient verbalized understanding of these risk and  consented to proceed.  OPERATIVE NOTE: Patient was identified in the preoperative holding area and the correct surgical  site was marked. Patient was then brought to the Operating Room where a formal time-out was  performed to confirm the correct patient, site, and planned operation. Monitored anesthesia care was  provided by the anesthesia team. A well padded tourniquet was placed on the upper arm. Patient was  then prepped and draped in the usual sterile fashion. Local anesthetic was then injected superficially  over the A 1 pulley of the affected digit. The hand was then exsanguinated and tourniquet inflated.  An approximately 1 cm longitudinal incision was at the distal palmer crease over the A 1 pulley of the  affected digit. We dissected through skin and subcutaneous tissue, being careful to retract the digital  nerves. Tenotomy scissors were then used to carefully spread the underlying tissue and retractors  place to expose the A 1 pulley. The A 1 pulley was then released sharply with the 15-blade midline. A  tenotomy scissor was then used to complete the release proximally and distally. We then confirmed  that there was no evidence of continued trigger. In addition, a Ragnell was used to pull the tendons  out of the wound to confirm the complete release of A 1 pulley. The wound was then copiously  irrigated and closed with two horizontal mattress 4-0 nylon sutures. Sterile dressing applied.  Tourniquet was deflated and patient transferred to recovery room without incident in stable condition.  VLab Outpatient Clinic Chart # 410327Identify the Primary procedure CPT codeIdentify the Primary Diagnosis ICD-10-CM codeIdentify the Secondary diagnoses  ICD-10-CM code